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Rule Details

Rule Number:

13P018

Title:

Guidelines for Distinguishing Between Primary and Specialty Mental Health and Substance Abuse Services.

Type:

Standard

Status:

Adopted

Agency:

Department of Financial Regulation

Legal Authority:

Act 171 of 2012 § 11e; 8 V.S.A. § 4089b.

Summary:

Vermont law requires a health insurance plan to provide coverage for treatment of a mental health condition and prohibits the plan from establishing a rate, term, or condition that places a greater burden on insured for access to treatment for a mental health condition than for access to treatment for other health conditions. A health insurance plan shall require no greater co-payment for primary mental health care or services than the co-payment applicable to care or services provided by a primary care provider under an insured's policy and not greater co-payment for specialty mental health care or services than the co-payment applicable to care or services provided by a specialist provider under an insured's policy. 8 V.S.A. Section 4089. This regulation prescribes guidelines for distinguishing between primary and specialty mental health services in order to implement this statutory requirement which takes effect on January 1, 2014.

The Department engaged Oliver Wyman, an actuarial firm, to calculate the premium impact associated with implementing this rule. The estimated cost of requiring insurers to charge an insured an amount no greater than that applicable to primary care medical services for those services deems to be primary mental health and substance abuse services is minimal. The actuarial firm estimated the premium impact to be only 0.11 for ever 5.00 decrease in co-pay for 2013. For example, a $10 decrease in co-pay would result in an increase in premium of $1.14 per month for single person coverage, and $2.97 per month for family coverage in 2013. A separate analysis was done to look at induced utilization, meaning consumers may utilize more services when c